Research Findings from the Women's Interagency HIV Study

This article is part of The Body PRO's archive. Because it contains information that may no longer be accurate, this article should only be considered a historical document.

Following are summaries of some of the research
findings on HIV positive women over the last few years from WIHS (Women's
Interagency HIV Study). This study was started in 1994 and follows women with
HIV and women at high risk of HIV every six months. See other stories in this
section for definitions of words in italic letters.

Cervix Woes

There is conflicting data about the
relationship between vitamin A deficiency and cervical cancer. A look at HIV
positive women found that vitamin A deficiency was associated with abnormal
Pap smears (the first step towards cervical cancer). It didn't matter if
the women had low T-cells or HPV (human papilloma virus), both of which are more
likely to be present in positive women with abnormal Pap smears. The vitamin
deficiency by itself was an independent risk factor. It was also related to
injection drug use and low income. (1999)

"Even in the face of HIV infection,
relatively immunocompetent women can eliminate squamous cervical
lesions," researchers reported. The likelihood of abnormal cytology [cell
findings] among women with HIV was high. Two out of three positive women had
abnormal test results, compared to one out of three negative women. However, the
so-called "cumulative risk" (over time) of HSIL (high-grade squamous
intraepithelial lesions) and cancer was not high. (2000)

Comparing a group of 2,000 positive women with 500
HIV negative women, researchers found that 38% of the positive women showed
abnormalities in their Pap smear vs. 16% of negative women. Positive women were
also twice as likely to have high-grade (significant) abnormalities (2.3% vs.
1.3%). The researchers reported that while infection with HPV most predicts Pap
smear abnormalities, other predictors included low T-cells, younger age (under
30), and ever having had tuberculosis. (1997)

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In a different report, the same group of
researchers noted that positive women were twice as likely to have HPV (58% vs.
27% of the negative women). Since then, four HPV types have been most strongly
associated with leading to cervical cancer. One group of researchers found that
women with HIV and HPV who developed abnormal cervical cells had equal numbers
of low-risk and high-risk HPV types. In contrast, 80% of the negative women with
cervical abnormalities had the high-risk strains. Therefore, even the "innocent"
strains of HPV can cause problems for positive women. (1997)

But there is really good news for women in the
HAART era! For women with Pap smear abnormalities, those who began on highly
active antiretroviral therapy (generally a triple combination of HIV drugs) were
less likely to continue having abnormalities. They were also less likely to have
HPV even if they had it before going on medication, no matter what their viral
load or T-cell count. "[HAART] appears to have a beneficial effect on coincident
HPV infection and disease," researchers concluded. (2001)

"Preliminary evidence suggests that immune
reconstitution following HAART impacts HPV-associated disease," researchers
noted. They found that women on HAART were more likely to have a lack of
progression in abnormal cervical cells. They even had regression of disease.
(2000) HAART use significantly reversed cervical abnormalities to normal or to
less severe. (2001)

Pap smears alone missed precancerous
changes in a third of positive women tested. Even using a higher level of
examination, a colposcopy, still missed precancerous abnormalities in a
third of positive women. Comparing these women's findings of abnormalities
further with a biopsy, in which a piece of cervical tissue is taken off and
examined, is what identified the seriousness of their condition. "Liberal use of
biopsy is essential for proper management of women with abnormal smears,"
researchers reported. (See also "Controversies,"
below.)

Deaths

The Centers for Disease Control and Prevention
(CDC) and WIHS both reported findings that active drug users who were HIV
positive had a substantial rate of death from non-HIV causes. The CDC in 2000
reported that in one group, many of the women were not using strong combination
HIV drugs available to them. Only one out of four of the women with less than
200 T-cells were on HAART. In this group, a third of the deaths not related to
HIV resulted from illicit drug use, and the CDC cited the need for hepatitis
vaccinations and better drug treatment options.

WIHS reported similar findings in 1999. "A
substantial minority" (one out of five of the deaths with known cause) were due
to non-AIDS related deaths. These included deaths from liver failure, murder,
suicide, and overdose on illicit drugs. "While the number of deaths from AIDS
has significantly decreased, the number of deaths from non-AIDS causes has
remained constant, and in the HAART period make up a higher proportion of deaths
among women with HIV. These causes of death need to be addressed if we are to
continue to reduce mortality," WIHS concluded.

Thrush

Researchers looked at the effectiveness of weekly
intravaginal application of Lactobacillus acidophilus gelatin capsules or
clotrimazole 100 mg tablets. There was a significantly longer time to the first
episode of vaginal thrush with clotrimazole, but not with the acidophilus.
Still, they reported that, "Both interventions reduced the number of episodes by
half. Vaginal yeast infections can be prevented with local therapy and
prophylaxis [prevention] should be offered to HIV infected women as part of
routine primary care." Elsewhere, a gynecologist, and HIV specialist, reported
that in her clinical experience, she had found that boric acid suppositories
prepared by pharmacists had cleared some yeast infections. (2000)

Period Woes

WIHS and other investigators reported on menstrual
abnormalities in women with HIV compared to those without HIV. After adjustment
for demographic differences (age, ethnicity, etc.), body mass index and
substance abuse, it was found that being HIV positive increased the odds of
having both a very short menstrual cycle and a very long menstrual cycle. Being
HIV positive did not increase the odds of having a moderately long cycle, or
affect average cycle length and variability. Although HIV may slightly increase
the possibility of very short cycles, HIV serostatus has very little effect on
amenorrhea (the absence or stopping of menstruation), menstrual length or
variability. Among HIV positive women, higher viral loads and lower CD4 T-cell
counts were associated with increased cycle variability. (2000)

Lung Woes

Researchers found twice the rate of lung infection
in positive women as in high-risk negative women. Eighty-five percent of all the
women smoked cigarettes and 50% used injection drugs. (2000)

Anemia

WIHS reported that women who used HAART for at
least 18 months had a reduced risk of developing anemia. There was also
resolution of anemia for those who had it before starting meds and increased
their T-cells or those who used HAART for more than 18 months. However, women
who continued to use Retrovir (AZT), which can cause anemia, did not see an
improvement. The researchers noted that, "Anemia is an independent risk factor
for decreased survival in HIV positive women." It is common in positive women,
more so with higher viral load levels (HIV in the blood), lower T-cells,
clinical AIDS, Retrovir use, low mean corpuscular volume (MCV, the size of their
red blood cells), and African American ethnicity. (2000)

Happiness

"Feeling bad lately"? You might if you
believe that, "There is nothing you can do [about getting sick] if you don't
have good health care." On the other hand, those women who believed "a person
can have HIV but never get sick" reported having more "excellent health" and
"feeling happy."

Women who said their health wasn't so good were
more likely to agree with the statement, "It is not worth following a difficult
health plan/regimen." The women who disagreed were more likely to say that they
did enjoy good health. (1999)

Depression

Depression leads to lower T-cells and greater risk
of death in positive women. The findings add to knowledge that depression is a
risk factor for death for positive people, male and female. (2001)

Transmission

The presence of STDs (sexually transmitted
disease) is known to increase the risk of becoming infected with HIV. A study
with Kenya women found that the presence of vaginal thrush and trichomonis lead
to greater shedding of HIV in their vaginal secretions, which may increase the
risk of transmission to their partner. (2001)

Another, very tiny, study found that cervical
inflammation and genital ulcers also increased HIV shedding. (2001)

Diabetes

Although new cases of diabetes were rare, they
happened twice as often in women using a protease inhibitor (3% vs. 1.3%). Even
improvements in viral load did not help this trend. Nevertheless, these was an
even greater risk of developing diabetes for those women on a protease inhibitor
whose viral load did not decrease. (1999)

Breast Cancer

Researchers reported unusual cases of breast
cancer seen in positive women, at an early age. The report needs follow-up
research to determine how significant this finding may be. (1997)

Childhood Abuse and Domestic Violence

A WIHS study of more than 2,000 positive women and
500 negative women found that two-thirds of the women had a history of domestic
abuse, including physical, emotional or sexual abuse. The study also noted that,
"A history of childhood abuse may identify women at increased risk for sexual
and physical victimization as adults. Further, childhood abuse is related to
increased participation in behaviors identified as high risk for HIV infection."
(1997)

Severe Inflammation

Atypical (not typical) or ASCUS

Follow-up Pap without colposcopy (may even do
colposcopy with one Pap with ASCUS); repeat every 4-6 months for 2 years until
three exams are negative; if two ASCUS findings in a row, do a colposcopy.

LSIL

Colposcopy with or without a biopsy.

HSIL and Carcinoma In Situ

Colposcopy with biopsy.

Invasive Carcinoma (Cancer)

Colposcopy with biopsy if there is a lesion, or
conization; treat as appropriate with surgery or radiation.

Taken from the 2000-2001 Medical Management of HIV Infection
by Drs. John G. Bartlett and Joel E. Gallant. The authors also note, "Newer
methods of cytologic evaluation [looking at cells] using liquid-based collection
and thin-layer processing may enhance sensitivity but have not yet been
evaluated in HIV infected
women."

Treatments

These treatments require local anesthesia and can
be done as an outpatient procedure (except the hysterectomy). Choice of
treatment depends on the location and size of the abnormal cervical tissue and
the extent of the disease being treated, among other factors.

Cone biopsy (also
called conization): Cutting off a section of precancerous or cancerous
tissue, done in the shape of a cone. General anesthesia may be used. In addition
to being a treatment, this procedure can also show whether cancer has become
invasive. This procedure can be done with a knife or with an electrical loop
(see LEEP).

LEEP (Loop Electrical
Excision Procedure): a biopsy done with an electric wire loop to slice off a
thin, round piece of tissue; can also use LEEP to perform a
conization.

D and C (dilation and
curettage): Stretching the cervical opening and using a curette (a small,
spoon-shaped tool) to collect tissue samples from the uterus. General anesthesia
may be used.

Cryotherapy
(freezing): destroys tissue, including warts, with an instrument called a
cryophobe, the tip of which has been cooled by carbon dioxide or nitrous oxide
gas. No longer recommended for HIV positive women.

Cauterization
(burning, also called diathermy): destroys tissue, including warts, by using
a heated instrument, an electric current, or a caustic substance.

Laser surgery:
cutting with a very thin beam of light.

Hysterectomy:
removal of the uterus, with or without the ovaries. Causes periods to
stop.

Controversies

Doctors swear by the Pap smear as the best method
of detecting cancer early. Just get one on schedule like you're supposed to. But
problems with the test have made media horror stories, showing women dying
unnecessarily from cancer that wasn't found early. Problems include negligent
labs that try to read too many smears a day and therefore whiz by dangerous
cells. Now there are new methods that can improve on the Pap smear. But, of
course, doctors are showing their conservative stripes with the old "it isn't
proven" line. The HIV docs, in turn, are saying, "it isn't proven to help women
with HIV."

A Pap with speculoscopy is a standard Pap smear
followed by a vinegar wash. Then a chemical light on a microscope is used to
look for abnormal cells. It's not much more expensive than the Pap, but the
difference is not paid by insurance. It is available at many Planned Parenthood
clinics. It's as sensitive (as good at catching abnormalities) as a colposcopy
with biopsy. That's an improvement over the standard Pap, but abnormal findings
from a speculoscopy will still need to be followed up by a colposcopy with
biopsy for confirmation. There's also a different type of Pap smear, in which
the handling of the cells differs. Instead of being smeared right onto a slide,
the cells are first put into a tube with liquid that helps sort out mucus and
other contaminants, and avoids clumping. The sample is then put on a slide as
usual. These Pap tests are called "ThinPrep." It allows for HPV testing, as
well, to see if you have strains that are highly associated with cancer. There
are also computerized readings of slides that may pick up abnormalities not seen
by cytologists (the people reading the slides). The ThinPrep people say a
computer program can't pick up abnormalities that aren't there because of a bad
sample collection. The speculoscopy people say a sample collection can't pick up
the abnormalities that haven't shed, but which the speculoscopy light can
see.

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